Summer Enrichment Program Enrollment (Math & Reading Bootcamp) Please take your time and complete this form. Step 1 of 5 20% Student InformationHow many students*01234Student 1Name* First Last Gender* Male Female Date of birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920School* Grade (Enter the child's next year grade or promotion grade)*K123456789101112Year*201820192020202120222023Student 2Name* First Last Gender* Male Female Date of birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920School* Grade (Enter the child's upcoming school year grade or promotion grade)*K123456789101112Year*201820192020202120222023Student 3Name* First Last Gender* Male Female Date of birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920School* Grade (Enter the child's upcoming school year grade or promotion grade)*K123456789101112Year*201820192020202120222023Student 4Name* First Last Gender* Male Female Date of birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920School* Grade (Enter the child's upcoming school year grade or promotion grade)*K123456789101112Year*201820192020202120222023Student 5Name* First Last Gender* Male Female Date of birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920School* Grade (Enter the child's upcoming school year grade or promotion grade)*K123456789101112Year*201820192020202120222023Student 6Name* First Last Gender* Male Female Date of birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920School* Grade (Enter the child's upcoming school year grade or promotion grade)*K123456789101112Year*201820192020202120222023 Parent/Guardian informationParent/Guardian Name* First Last Phone*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Alt PhoneEmployer Work Phone Emergency Contact InformationEnter the names of those authrozied to pick up your child.Contact 1 Name First Last Contact 1 PhoneContact 1 Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact 2 Name First Last Contact 2 PhoneContact 2 Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Permission & ReleasesI give AKCCL's authorized personnel permission to transport my child, in the event that I or the contact(s) list above is unavailable or unable to be contacted, and my child requires transportation. I give my child permission to participate in all physical education activities. I consent to the use of any photograph of my child/dependent/self, and/or any copies of this photograph in any editorial and/or promotional material produced and/or published. **In case of an accident, serious injury, or illness, the program will contact you. In the event that we cannot reach you, your signature below authorizes officials of the AKCCL to take whatever action is deemed necessary, in their judgment, for the health and safety or your child. It is given to provide consent for medical care.** Permission Granted* Yes Health InfomationMedical ConsiderationsPlease indicate if your child has any specific medical considerations on the lines provided. ( Allergies, food, medication, etc. ) Do you want to apply for Scholarship Subsidy? Yes No Fees are reduce up to 40%. Special consideration will be given to families of low income and Senior Citizens raising children. However, all applicants will be considered.Number of Household Members*0123455678910Name and Date of Birth Name Date of Birth Name and Date of Birth Name Date of Birth Name and Date of Birth Name Date of Birth Name and Date of Birth Name Date of Birth Name and Date of Birth Name Date of Birth Name and Date of Birth Name Date of Birth Name and Date of Birth Name Date of Birth Name and Date of Birth Name Date of Birth Name and Date of Birth Name Date of Birth Name and Date of Birth Name Date of Birth Reason for Request (Check all that apply) Financial Hardship/Low Income Failing/Low Performing Student Three or more students enrolled Gifted Student Scholarship Subsidy File (Child's Medicaid Card or Proof of Income) Drop files here or Select files Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 1 GB. Provide documentation to support your request such as proof of income(check stub/social security benefit/Tax Return), report card, etc.You may type or provide your explanation below.Registration CostDeposit/Registration is fifty dollars ($50.00) per student. This registration secures your child's slot.Authorization* Yes Checking this box confirms authorization of payment and indicates that I have provided the information above to the best of my ability.